This Week: EHRs & The Nurse’s Voice, Collusion & A Nurse Asks for Help

A physician, standing in a busy hospital unit, was overheard telling a resident,

“If you want to be certain something gets done for your patient, find the busiest nurse in the unit, and ask her to do it.”

It’s true, nurses thrive on getting the job done.

Here at JParadisiRN blog, things are hopping. Besides transitioning to a new employment opportunity, I’ve been busy writing, and making art.

In case you missed it, Do EHRs Rob Nurses of Voice and Oversimplify Descriptions of Patient Care? is the title of my latest post for Off the Charts, the blog of the American Journal of Nursing. While I mostly love EHRs, the voice of bedside nursing is lost by reducing the nurse’s note to check boxes and smart phrases. However, not everyone agrees. What’s your opinion? BTW, the I made the collage illustrating the post; the text is from Florence Nightingale’s Nursing Notes.

Weekly, I write and illustrate a post for TheONC, The Oncology Nurse Community website. This week’s post, Which Came First, The Chicken or the Nurse? ponders the lack of privacy and personal space for nurses.

Chapter 13 of The Adventures of Nurse Niki is posted. In  Collusion, Niki’s creative solution for managing her patient’s under medicated post-surgical pain last week yields an unexpected result, in which she coaches a father how to ask his daughter’s surgeon to treat her pain. How do you handle similar situations?

I receive comments from nurses, some asking questions. A recent comment submitted to an older post, Of Medication Errors and Brain Farts is a single line,

I made a med error and lost my job how do you go on

If the comment touches you, please reach out with support and advice for this nurse in replies to this comment. Let’s help out a fellow nurse, yes?

Advice for Administering Medications with Narrow Safety Margins

I read the order carefully, looked up the medication, and consulted with a pharmacist before giving it. Signing the medication administration record (MAR), I re-read the order. I did not see the same dose I read the first time.

by jparadisi

by jparadisi

Immediately, the blood rushed up from my feet to my ears, and I was lost in pounding waves of white noise. I made a med error! A serious one! I didn’t say these words out loud. Instead, I placed the patient’s chart and the empty, pre-filled syringe in front of the charge nurse. “I think I just made a med error — a bad one. Look at the order and the syringe. What did I do?” She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise subsided into the gentle lapping of my breathing.

Medication errors are potentially heart stopping: figuratively for nurses, verily for patients. ICU  and Oncology nurses have the added stress of routinely administering medications with  narrow safety margins to patients willingly offering their venous access. Further, neonatal and pediatric nurses have patients with less tolerance to any medication or fluid error than their adult counterparts.

While all nurses make medication errors, our goal is to develop strategies to avoid them:

  • Always check chemotherapy or any high risk medication orders beyond the five rights of medication administration. Our oncology services have standardized the double check into a checklist developed from the ONS Safe Handling of Chemotherapy and Biotherapies Handbook. It includes monitoring lab values, confirming appropriate regimen, lifetime dose (if applicable), calculating the correct volume of medication in solution, and more.
  • Don’t rely on memory: Look it up. Pharmacists are also a resource.
  • Consult with more experienced nurses, but don’t rely on their memory either. Look it up.
  • Do not allow interruptions during a medication check. This is not a time for multitasking.
  • Maintain current chemotherapy or other applicable education.

Despite precautions, errors will still occur. Owning and learning from them is the quickest way to move past a bad experience. Supporting a culture of safety in the workplace increases rates of both error reporting and prevention. Colleagues should extend support to one another.

Does your institution have a “culture of safety”? What advice would you add about error prevention? What experiences would you share?

Lessons About Medication Errors From Baseball

In the commercial, three guys are standing around a grill, talking about baseball. One of

painting by jparadisi

Baseball Card by jparadisi

them quotes a stat.

Another one says, “Really? Are you sure?”

The first guy says, “I’m 99.9 percent sure.”

The third guy says, “Then you don’t know.”

I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.

I was reviewing the chemotherapy orders:

  • Patient name and identifiers: √
  •  Orders are dated with today’s date: √
  •  The chemotherapy ordered is appropriate for the patient’s diagnosis: √
  •  The dosage is correct: Uh oh. Wait a minute.

The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:

xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug

The doctor meant to write:

xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug

I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.

To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.

I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”

“Yes it would,” I said. “Are you certain?”

“I’m 99.9 percent sure.”

“Certain enough to sign your name to an order?” I asked.

There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”

I thanked her.

The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.

I was 100 percent certain the infusion was correct.

Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?

Tips for Learning Chemotherapy Administration

I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.

photo by jparadisi

photo by jparadisi

Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.

I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”

Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:

Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.

Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:

  • Right Patient
  • Right Medication: In oncology, this includes becoming familiar with the overarching chemotherapy regimen ordered.
  • Right Dose
  • Right Route
  • Right Time

Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.

Teach evidence-based practice, not your old war stories. None of us older nurses are as entertaining to new nurses as we think we are. As a preceptor, keep your pearls of wisdom short and relevant to the teaching situation.
“Knowledge isn’t knowing everything but knowing where to find it,” said my ninth grade algebra teacher. Teach new oncology nurses the value of looking up medication administration information in your facilities’ policies and up-to-date references. Assuming the information provided by a coworker is reliable instead of looking it up yourself is unprofessional, and won’t hold up as your defense in a sentinel event review.
What helpful advice would you offer new oncology nurses?
What oncology references do you find particularly helpful?

Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one. Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, “I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.” She stopped what she was doing. She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, “I know exactly what you’re feeling.”

I felt relief. My patient was safe. It was a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed.”If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors…” She was a great nurse, not a perfect one.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

Interruptions Increase Errors. Really?

              

Nurse's Note artist: JParadisi. pencil and ink on paper

     I am writing this post while my husband pumps air into his bicycle tires in our living room (ka-chunka chunka-chunka), muttering about how much work cycling is. Finding uninterrupted time to write or paint is sometimes challenging. In nursing, where the safety of patients depends on accuracy, it is impossible. It is the biggest absurdity of my two careers.    

      This morning I read a Medscape article about interruptions exponentially increasing nursing medication and procedure errors. Researchers collected data for the study by observing nurses at two hospitals. Although the conclusion seems obvious, I appreciate hard numbers applied to a reality all nurses recognize. Collecting data is the first step towards change. Shockingly, according to the study a single interruption during medication administration increases frequency of errors to 25%.    

     In all my years of nursing, I have never completed a single task from start to finish without an interruption. A coworker asks a question, a patient or family member needs something, a phone call from a physician or another department and I am distracted. Once, on pediatric unit, I entered my first patient’s room to find him vomiting violently in the bathroom. While holding his small head out of the toilet, calming him down, and keeping his IV in place, my pager beeped. I had to ignore it, but as soon as the patient was safely in bed, I went to the nurses’ station to see why I was paged. There, a unit secretary lectured me about her expectation for an immediate call back to a page (although doctors have an unwritten, twenty-minute grace period to answer pages for non-urgent matters). Why was I paged? A doctor had a question. I did not need to explain myself to the secretary; when I did, her expectation remained unchanged. Whatever. I called the doctor back, and there wasn’t a problem. My point is interruptions can wait until a patient is safe. The problem is most nursing units have expectations that everything be done now. STAT is the most over-used word in health care. Is there really such a thing as STAT Colace? There is an unrealistic pressure on nurses to do everything at once. It is impossible, and patient safety suffers. It’s a no brainer. How sad studies are necessary to prove the obvious.    

        Creating a safe zone where nurses can draw up medications without interruption is a reasonable idea; however, it does not address the interruptions occurring in the patient’s room, like the pager going off in my pocket.  I am often interrupted while double-checking blood, accessing a port, or hanging chemo by the patient asking for a blanket “when you get a chance” or answering their cell phone. They do not realize how much concentration it takes to give safe care. More than once, I have explained to patients or family members “I need to focus on what I’m doing to keep you safe, and I will be glad to answer your question as soon as I finish.”  I’ve never had a patient or family member complain about it. They appreciate dedication to their safety.   

     Interruptions are a daily part of everyone’s life. Reducing nonessential ones is crucial to safe nursing practice, and adjusting expectations (including staffing ratios) is critical.     

     You can find the article   

Interruptions Linked to Medication Errors by Nurses    

At  medscape.com

Comparing Apples to Oranges: Pharmacist Eric Cropp & Registered Nurse Anne Mitchell

     On Tuesday, February 16, 2010, JParadisi RN’s Blog had the most site hits since its debut in January, 2009. The day is notable, because the blog’s post Whistle Blowers & Patient Advocates: When the Nurse Stands Alone was mentioned by Shawn Kennedy on the AJN blog, Off the Charts.  I assumed the two events were connected. Imagine my surprise: they are not. The stats for JParadisi RN’s Blog show that the most popular post on February 16 was an older post:  Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient. For the entire week that post and the posts with updates about Eric Cropp were the most viewed on my blog.

     Eric Cropp served 6 months of imprisonment for involuntary manslaughter in the death of 2 year-old Emily Jerry. Emily Jerry died when she received a chemotherapy solution containing a lethal dose of sodium chloride mixed by a pharmacy technician at the hospital where Eric was the supervising pharmacist. The Ohio Board of Pharmacy stripped Eric of his license prior to his conviction.  Now a convicted felon, he will never practice pharmacy again.

     Why the renewed interest in the Eric Cropp case, during the immediate aftermath of the Anne Mitchell trial? Anne Mitchell, RN was publicly supported by the Texas Nurses Association and the American Nurses Association. The TNA donated funds for Mitchell’s legal defense, and the Texas Medical Board acknowledged Mitchell’s duty as a patient safety advocate. Mitchell was found not guilty. There were no fatalities in the Anne Mitchell case. The most obvious difference drawn from a comparison of the two trials is that a child’s death initiated the criminal charges against Eric Cropp. Perhaps this explains why pharmacist professional associations appear silent on the matter. Searching  two prominent organizations websites with the keywords “Eric Cropp” I found only one article about the case on one site, and none on the other. Granted, defending a person accountable for the accidental death of a toddler creates an unpopular challenge in public relations. 

     Physicians are familiar with lawsuits involving the death of patients.  It is rare for a doctor to go to prison or be stripped of his or her license in such a case.  Eric Cropp was convicted of criminal charges in the absence of public support, except for  Michael Cohen of ISMP.  Whether this is right or wrong is a matter of opinion.

     The  pharmacy profession lost an opportunity to speak about patient safety systems, staffing issues, medication compounding practices, pharmacist to technician ratios, and other problems similar to those nurses have brought to public attention for years.  In contrast, the TNA, and ANA used Anne Mitchell’s trial to educate the non-medical public about the patient safety advocate role of nurses. It is important to remember that the non-medical public is unfamiliar with common hospital practices. In my opinion, there is an expectation for professional organizations to educate the public on the scope of practice of its members. It is unfortunate that this opportunity was missed during the Eric Cropp trial. 

     Did a lack of support and public education lead to the setting of  a disturbing  precedent: the criminalization of medication errors? (Will the Criminalization of Medication Errors Make Patients Safer in Ohio?).           

     Eric Cropp was released from jail on February 15, 2010, and this explains the increased traffic to JParadisi RN’s Blog on February 16, in the aftermath of the Anne Mitchell case. It was only a coincidence. Whether or not pharmacists compare the two very different outcomes of these trials, I do not know.

      I am married to a pharmacist.  However, for most of my career, I was a pediatric intensive care nurse dedicated to saving the lives of children like Emily Jerry. I saw firsthand families devastated from losing a child under less unusual circumstances. The opinions expressed in this post do not diminish my sympathy or empathy for the family of Emily Jerry.

Eric Cropp Talks to ISMP about the Medication Error Leading to a Child’s Death

     The Institute for Safe Medication Practices (ISMP) has published a follow-up article regarding the case of  pharmacist Eric Cropp in the December 3, 2009 issue of Medication Safety Alert! Acute Care, Eric Cropp Weighs in on the Error that Sent Him to Prison. In this article, Eric discribes events contributing to the fatal error.

     Eric Cropp is the Ohio pharmacist who is serving 6 months imprisonment as part of his sentence after conviction for the death of  2 year-old Emily Jerry.  The child died after receiving a dose of chemotherapy mixed in a hypertonic saline solution by a pharmacy technician. My original post on this case, Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or his Patient, discusses the circumstances of this catastrophic medication error.

     For readers following this story, please read Eric’s version of the events leading to the error, which has devastated the lives of the Jerry family, as well as Eric Cropp’s.

Aftermath of the Eric Cropp Sentence: Will the Criminalization of Medication Errors Make Patients Safer in Ohio?

     Although medication errors are not the focus of this blog, I feel it’s important that health care professionals know what is occurring in the state of Ohio, in the aftermath of the Eric Cropp sentencing referenced in this blog’s post Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp  or his Patient (September 5, 2009).

     According to the September 10, 2009 issue of  The Institute for Safe Medication Practices, Legislation has been introduced in Ohio that would establish criminal penalties for pharmacists, pharmacy interns, and qualified pharmacy technicians who fail to report suspected dispensing errors with a “dangerous drug” to the Board of Pharmacy(legislature.state.oh.us%2fbills.cfm%3fID%3d128SB+119)  Criminal penalties would include fines of up to $250 and 30 days imprisonment. Three or more convictions within 6 months would result in increased fines and up to 180 days imprisonment. The Board of Pharmacy would also be required to investigate all errors and pursue disciplinary action if warranted”

The article goes on to say

ISMP adamantly encourages reporting of medication hazards to promote learning. But you can’t punish people for not reporting errors and then subject them to punishment if they do report errors…Ohio pharmacy staff are ” damned if they do” and “damned if they don’t” report errors; in either circumstance, they face the very real threat of imprisonment, fines and a criminal record.”

     Will this type of legislation create a safer environment for patients? Will other states follow suit? Will legislation such as this be applied to health care providers who administer medications, such as nursing instructors training students in clinical rounds, or nurse preceptors? (remember, pharmacist Eric Cropp did not mix the hypertonic chemo, a pharmacy technician did)  Will it drive people away from careers in health care professions? 

Read the full article at http://www.ismp.org/newsletters/acutecare/currentissue.asp 

    

 

Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient

     The Institute for Safe Medication Practices (http://www.ismp.org/) published an article in their August 27, 2009 newsletter, describing a horrific medication error that ended in the death of a child in an Ohio hospital. Just typing that sentence brings tears to my eyes.

     On August 14, 2009, Ohio pharmacist Eric Cropp was sentenced to 6 months in prison, 6 months of home confinement, 3 years of probation, 400 hours of community service, $5,000 fine, and payment of court costs. The Ohio board of pharmacy has permanently revoked his license. He did not mix the chemotherapy.  It was mixed by a pharmacy tech, who inadvertently used 23% saline as the base solution for the infusion that killed the child.

     Documentation from the case further shows that on the day the medication error occurred:

  • The pharmacy computer system was down in the morning, leading to a backlog of physician orders.
  • The pharmacy was short-staffed on the day of the event.
  • Pharmacy workload did not allow for normal work or meal breaks.
  • The pharmacy technician assigned to the IV area was planning her wedding on the day of the event and, thus, highly distracted.
  • A nurse called the pharmacy to request the chemotherapy early, so Eric felt rushed to check the solution so it could be dispensed (although in reality, the chemotherapy was not needed for several hours)

     The article Ohio Government Plays Whack-a-Mole with Pharmacist defends the right of health care professionals and patients to expect safe and consistent systems and policies  from hospitals to prevent the conditions and circumstances creating unsafe work environments, such as the one that has destroyed the life of a child, her family, and pharmacist Eric Cropp. Please read this article.